matt2401

Other posters have left some great information so I will try not to re-post. Here are some highlights of things I believe are improtant: Almost every single patient that comes in with critical high BGL levels are severely dehydrated. Expect all the changes that come with dehydration and plan for a large fluid bolus. If the patient is in DKA they may be in severe acidosis. The treatment of choice for this is fluid boluses. If the pH is critical low (usually less than 7.0) then possibly a bicarb drip BUT this will cause a drop in potassium on top of all the insulin they are getting. Montior the potassium levels closely as they get treated. As for labs the two numbers that will closely guide your treatment are: BGLs and Co2 levels on the BMP. The lower the initial Co2 level, the sicker they are. A more accurate way is to look at anion gap (some labs generate this automatically on the print out, otherwise epocrates has a good anion gap calculator). The higher the anion gap, the sicker they are. These numbers will trend very accurately in the opposite direction as treatment is given. It is helpful to understand the entire picture that the labs present, but those are your two "quick look" items. When BGL drops to less than 250 or so (hopefully you have shipped them to the unit, but you never know) the IV fluid must be changed to either D5 1/2NS or a D10 drip needs to be added. The cells in the body are starved for sugar, the treatment involves "pushing sugar in" with the insulin and later insulin with D5, etc. Remember to check serial BMPs!!! Potassium will fall dramatically with an insulin drip. Be very wary of an intial K of less than 5 when you start a drip. I promise it will be I hope this helps. Again, I cut out alot of the important stuff that was already posted. Good luck in your nursing career! Matt

Precedex for induction is just plain insane. I can't see how any doctor in his right mind would look at either 1) the FDA labelling, 2) the mechanism of action, 3) the literature available and say "hey I am going to use this to intubate a patient. Stupid, Stupid, Stupid. Our facility allows a max dose of 0.7mcg/kg/hr. There are two patient populations that I LOVE precedex in: CIWA/ETOH withdrawal patients and those anxious on BiPap. The first CIWA patient I talked an intensivest into using it on was buck wild crazy on 10mg/hr of Ativan (not intubated). Precedex 0.1mcg + Ativan 0.5mg/hr = RASS of -1 and a very happy nurse.

DAMN STRAIGHT!!!

So, I take it from your post that you are happy with your 3% pay raises while the management gets HUGE increases? Heck, that 3% will be eaten up from the massive insurance increases HCA is rolling out. "rumor has it they have a year to get a contract". That quote tells me you understand nothing about collective bargaining. Sounds like your a manager upset that 93% of your employees were fed up with your unsafe staffing grids, poor pay, etc. The employees have spoken, time to reap what you sow.

These words are as true today as when Jack London wrote them: After God had finished the rattlesnake, the toad, and the vampire, He had some awful substance left with which He made a scab. A scab is a two-legged animal with a corkscrew soul, a waterlogged brain, and a combination backbone made of jelly and glue. Where others have hearts, he carries a tumor of rotten principles. When a scab comes down the street, men turn their backs and angels weep in heaven, and the devil shuts the gates of hell to keep him out. No man has a right to scab as long as there is a pool of water deep enough to drown his body in, or a rope long enough to hang his carcass with. Judas Iscariot was a gentleman compared with a scab. For betraying his Master, he had character enough to hang himself. A scab hasn't. Esau sold his birthright for a mess of pottage. Judas Iscariot sold his savior for thirty pieces of silver. Benedict Arnold sold his country for a promise of a commission in the British Army. The modern strikebreaker sells his birthright, his country, his wife, his children, and his fellow men for an unfulfilled promise from his employer, trust, or corporation.

Hi all, recovering RN here. 4+ yrs clean. I personally did not use suboxone for my detox (I detoxed myself) but I see no reason why it can not be employed as tool in detox/recovery. I have seen many people successfully use suboxone for an extended period of time and have no indication of any sort of impairment, although admittedly I am not qualified to say that for sure. I have also seen suboxone used in a rapid detox. My feeling on suboxone is that it is a reasonable treatment when prescribed by an addictionologist. My own personal "rule" towards my dealings with doctors on potentially controlled substances are: If I am in pain to where an OTC NSAID is not effective I will always seek the opinion of a medical doctor. No self medicating ever! I never "ask" for any specific medication. I explain to the doctor that I am in recovery and the pain that I am having. I leave it to his/her decision what the best treatment is for me. Sometimes I specifically ask for no narcotics for various reasons. I never exceed the amount to take or increase the frequency on my own of any medication. If the medication is not working, I call the doctor and explain the situation and leave it to his or her judgement on how to proceed. I have gotten through three surgeries in recovery (yea, crappy luck for four years!) with this. Two of them I threw out my narcs when I no longer needed them. (One was intensely painful!). Why am I sharing this? I think this same model would work well for detox. If symptoms are too painful, explain the situation and allow the judgment of the doctor managing the detox to decide the best course of action. To me, this is my part of "letting go and letting God" take care of it. It takes some faith that the person managing your care will do so effectively. I know my higher power has been with me for a few 24 hours, I don't think he is going to leave me anytime soon. Matt

I have been seeing ALOT of fairly health patients coming in with URI s/s then crashing HARD and ending up on a vent/oscillator, multi-pressors then dying (usually within 24 hours of admission but sometimes just languishing). They aren't technically fitting ILI symptoms and we are being aggressive about influenza swabs, but they are finding as low as 10% sensitivity for the rapid test to pick up on swine-origin H1N1 flu (the latest, correct term of the week). The PCR confirmation tests from the health department take so long to get back, its almost useless. I have been talking with other nurses in my area and they are seeing the same thing at other hospitals. Local event? Happening other places? I have a really bad feeling about this fall....hope I am wrong

RSI is the best and safest way to go. I bring this expierence from my paramedic years of dealing with many, many ODs. Most are polysubstance and difficult to treat. If you give narcan you run the risk of reversing the narcotic component and causing vomiting, but still too lethargic from other meds (benzos and soma go hand in hand with narcs) to protect the airway. Now you have aspiration pneumonia, oops. Ah, but there is Romazicon one might say; well only if you want to start seizures from acute benzo reversal (and no way to treat them because all the benzo receptor sites are bound). Activated charcoal has never been shown to produce any better outcomes. Plus, dumping fluids in the stomach of a sedated and lethargic patient would make me nervous for aspiration. The best and safest approach is to RSI and let the meds wear off. If the patient goes into DTs, all the better to manage on an Ativan or propofol gtt while vented. I would completely agree with the order to intubate, it is safest for the patient and the staff. I try and limit Narcan use to when it is known to only be narcotic (i.e. patient got 2 mg Dilaudid and now is over sedated). On the flip side, if the intubation was over aggresive then the gases will be great the patient will wake up and they will get extubated. People get intubated every day in the OR for elective procedures so its not like its a "punishment" or non-treatment. Here is an SBAR suggestion that you asked for: S: Patient was admitted to the unit from the ER with extreme lethargy, poor ventilations and periods of apnea. VS are....blah blah blah, latest ABG is: blah blah blah B: Patient presented with intentional OD of known/unknown subtances, reportedly taken by IV route. Treatment prior to the unit was.... A: I am calling because I am concerned about her airway protection and ventilation status R: Defer this one and let the Doc make the first "recommendation". Some Docs LOATHE being told what to do, even though you are coming from the patient advocate role. If you agree with it, fantastic. Doc gets to be 'Doc' and save you having to defend yourself. If you dont agree, then make your recommendation. Getting the orders you want can be a silly little game sometimes, esp when you are still new. Plus, the doc just might know something we dont (happens occasionally, ) Keep it short, sweet and to the point. Have all your labs ready to respond with (but not necessarily offer). Hope it helps! Matt

First, with the SpO2 remember it is giving you insight into only one component of the respiratory status: Inferred PaO2. Basically the pulse ox will give you a (usually) very good indication of what the PaO2 is. The rest of the compenents are: PaCO2, pH, Bicarb (blood gases), what the lung sounds are (indicating fluid, bronchoconstrictions, etc), what the chest x-ray looks like, what the baseline is and a few other things. The short answer to your question of "should I worry about a sat of 83%?" is: sometimes yes, sometimes no. I know, crappy answer! Everything else being equal, I am mildly concerned about a sat in the low 80s. I am much more concerned when that sat is on high flow O2. I am very worried if my patient that was in the upper 90's is in distress and now in the low 80's. See how you have to kind of put the picture together? Don't worry, it comes with time. How do you know what to do? Ask questions. Lots of them. Learn who gives you answers that make sense (some people are morons and try to pretend they know what they doing....they are VERY dangerous). Ask "why are we not treating this spo2 of 83%, but we are treating patient X differently?". Resp techs are great resources, the ones that migrate to ICU are usually at the top of their game. Lastly, ALWAYS treat the patient not the monitor (applies to pulse ox as well). The disposable probes we use are notorious for all of a sudden reading 70% with a great waveform for a minute or two then popping right back up to 99%. I walk in the room, patient is warm pink and dry in no distress. I treat my patient, not what the little number shows...:)

Hmmm, well the brain dead patients I have had were all organ donors and let me tell you....I was waaaaay too busy to sit and talk to them. Having said that I didn't have a desire or thought to talk to them. I did give a prayer of thanks for thier gift of life though. The last organ procurement I was in, the organ donation coordinator had everyone do a 'time out' before incision to have a moment of silence for the patient and family. That was so touching to me. Now I guess this kind of also applies though. When I have a patient who is in the process of dying (bradying down, agonal resps, etc) and DNR I have my own little 'ritual'. If there is no family or visitors with the patient I stop what I am doing, pull a seat next to the patient and hold their hand. I may comb their hair, do something 'nursy' (God I hated that term in nursing school, but I kind of get it now). I try and always make sure that when my patient dies, they aren't alone. Can my patient hear/feel/sense me? I don't believe so, but it just seems the 'right' thing to do in my gut.

I went to Lake-Sumter on the Paramedic to RN bridge (which had us in with the LPNs so same program). AWESOME program, I can not say enough about it. I compared my expierence with people going to DBCC, SCC and VCC and I had it made. Send me a message if you want to know more about it.

First a couple of things to realize. In this area, at least at my hospital; Oct, Nov and Dec are traditionally low census months. It picks up around now until April or so. If the census is low, it makes it easier for managers to justify a hiring freeze. Second, every story you read about the economy being so bad and how many millions of jobs lost = people without insurance. As the un-insured rises, hospital revenues decrease and the pinch comes....you guessed it, in staffing. Is there a nursing shortage? Yup! Are the hospitals going to address it as aggresively as before? No. Yes, they will hire expierenced nurses if they have to. Options? I would suggest passing the NCLEX before applying. If you get hired as a GN and fail the first time you are bounced back to CNA until you pass. The fail rates on the NCLEX really shot up this last year after they re-did it. You will be more employable with an RN after your name than GN. After that, keep you options open, get the work you can and use the time waiting for the job you want to get all the education you can. BLS/ACLS/PALS are all good things depending on where you want to go, maybe work on the BSN? Things are cyclical. I myself am hoping for substantial healthcare reform this year at the federal level. Say all you want about 'socialized medicine' (which is completely the wrong term, but I digress). If more people have insurance, our jobs are more secure. Matt

The only patients I have refrained from suctioning are the patients that are requiring high PEEP levels to maintain minimal PaO2s. In those patients when you break the circuit (the suction is going to break the PEEP) it is going to take 30 mins or so to build up the PEEP again. Of course, if they are plugging off and the peak pressures are >50, then they need it. Seems silly to me to say that all vent patients should not be suctioned.

Wow, you get report? Lol, our hospital went to just faxing a report then the patient comes 15 mins later! Thats always awesome when a patient rolls in just as your other patient (or patients) are crashing. If it were me I would focus on what treatments NEED to be started in the ER, which ones can be turfed to ICU. For example I had a patient sit down in the ER with an INR of 7, actively bleeding GI for two hours. Do you think the STAT vitamin K or STAT packed RBC (4 units for HGB of 4) was given? If you answered no, you win the cookie! Yes, they were on the admission orders but c'mon. A subQ injection has to wait? After that I would focus on the core measures type stuff...antibiotics given quickly but cultures drawn before. Heavy on 12-lead ECG interp, NIH scoring, pharmacology of ACLS/critical care meds.

Yes, the dosing schedule goes to 1mg/kg instead of 40mg (or 30mg with reduced CrCl). Still usually given SQ, although there is a dosing approved for IV in ACS. Lovenox has the benefit of no PTT monitoring required, and decreased risk of HIT. Back to the original question, TED in DVT. My guess is that it wouldn't hurt but it certainly wouldn't help. Remember, TED hose is meant to squeeze the veins together to allow the incompetent valves to work better and prevent blood backflow/stagnation. Once a clot is formed, that pressure would be meaningless. SCDs are certainly contraindicated. In reality TED hose are a waste of time. A Greenfeld filter is the only thing that could have prevented the PE.